Medical Report
Associate Level Material
Medical Report
This assignment is for you to create a screening tool for potential hires in your health care facility. As the health care administrator, you would want to ensure that your future employees have a strong understanding of medical reports and medical terminology. You are writing these reports for the applicants to read, interpret, and answer a set of questions you have developed. Refer to the samples of medical records reports on pages (142-144, 196, & 261-263) of the textbook. Each medical record should be completed and contain two questions you would ask of the potential hires.
The following suggestions will help you get started:
• Sometimes it is easier to start at the end. Think of the diagnosis the patient will receive. If you know what the end diagnosis will be, it makes it easy to know what symptoms, signs, and diagnostic methods would be used to achieve that diagnosis.
• For the History of Present Illness, consider what questions the physician might ask the patient about his or her chief complaint and symptoms and then chart that in this section. This section serves as an account of what the patient would report, based on their symptoms. Remember, symptoms are subjective, in that they are conditions experienced by the patient, and are therefore included in the patient history.
• For Past Medical History, document anything the patient may indicate in terms of past medical conditions that would be relevant to his or her current illness.
• For the Physical Exam section, document the observable signs. Signs are objective, in that they are measurable conditions, and therefore included in the physical exam. This includes vital signs or anything observed by performing the patient physical exam.
• For the Diagnostic/Lab Results, include the testing or procedures required to prove this diagnosis.
• For the Impression/Discussion, indicate the patient diagnosis and what the plan is
Medical Report
This assignment is for you to create a screening tool for potential hires in your health care facility. As the health care administrator, you would want to ensure that your future employees have a strong understanding of medical reports and medical terminology. You are writing these reports for the applicants to read, interpret, and answer a set of questions you have developed. Refer to the samples of medical records reports on pages (142-144, 196, & 261-263) of the textbook. Each medical record should be completed and contain two questions you would ask of the potential hires.
The following suggestions will help you get started:
• Sometimes it is easier to start at the end. Think of the diagnosis the patient will receive. If you know what the end diagnosis will be, it makes it easy to know what symptoms, signs, and diagnostic methods would be used to achieve that diagnosis.
• For the History of Present Illness, consider what questions the physician might ask the patient about his or her chief complaint and symptoms and then chart that in this section. This section serves as an account of what the patient would report, based on their symptoms. Remember, symptoms are subjective, in that they are conditions experienced by the patient, and are therefore included in the patient history.
• For Past Medical History, document anything the patient may indicate in terms of past medical conditions that would be relevant to his or her current illness.
• For the Physical Exam section, document the observable signs. Signs are objective, in that they are measurable conditions, and therefore included in the physical exam. This includes vital signs or anything observed by performing the patient physical exam.
• For the Diagnostic/Lab Results, include the testing or procedures required to prove this diagnosis.
• For the Impression/Discussion, indicate the patient diagnosis and what the plan is
References: | |Retrieved from http://www.webmd.com/heart-disease/clogged-arteries-arterial-plaque | |Retrieved from http://www.nhlbi.nih.gov/health/health-topics/heartattack/causes.html |